Clinical Case 1 Scenario and Surgical Options for Basal Cell Carcinoma

Glenn J. Hanna, MD: Let’s spend a few minutes on clinical case scenario No. 1. This is a 72-year-old male residing in Florida, it’s likely he has a fair amount of sun exposure in the past or present, who presented to a dermatologist with a nonhealing 3-cm ulcerative lesion on the lateral aspect of the dorsal nose. The patient has hypertension and probably well-controlled diabetes. A biopsy is performed that demonstrates an infiltrated basal cell carcinoma with evidence of perineural invasion. Let’s turn to Dr Emerick, our surgeon, and talk a little bit about with this kind of case presentation, what are the main treatment goals of surgery in basal cell carcinoma? How do we distinguish what’s appropriate for, perhaps, a Mohs or dermatologic surgeon, as well as a head and neck surgeon, and what would be your approach in this case?

Kevin Emerick, MD: Surgery is the best modality of treatment when it comes to curing basal cell carcinomas. That’s typically for small, well behaved basal-cell carcinomas. When I hear a case like this, there are a few things that start to perk up in my mind as I think about them from a surgical perspective. If I see a basal cell that’s bigger than 2 cm, I pause when it’s on the head or neck, which for me, is everybody. But when we think about head and neck behaving perhaps differently, when we see them invading deeper, in or beyond the subcutaneous fat, these are really important potential prognostic factors that can tell us that this might be that small group of basal cell that we can’t just do a small in-office procedure for. The clinical examination here is important. There can be a 3-cm ulcerated spot on the side of the nose that still feels really mobile, it still feels like it’s contained to the skin. But there can also be 3-cm ulcerated spots on the skin that go all the way through, they come to the inside of the nose, maybe they have pain, maybe they already have some dysesthesia or numbness because of that perineural invasion is more than just little stuff in the dermis, maybe it’s really big.

For me, as a surgeon, I started with those clues to make sure this is something that I want to be thinking about with surgery. If I start to think, “Gosh, this might be a little bit deeper, a little bit thicker,” then I think about imaging, imaging to help guide how deep does this go. Does this come into some of the underlying bone? These are the important things for me as a surgeon that are going to define the resectability of this in terms of, can I get it all out, and what’s the functional impact of getting it all out? I also start to think about those risk factors I mentioned earlier, of whether they’re at risk for a regional metastasis. While we don’t think about regional metastasis in general for basal cell, once you start getting greater than 2 cm on the head and neck, deep invasion, and especially when they get really big, over 4 cm, then we’ve got to think about regional metastasis as well.

Those are the things I start thinking about as a starting point, should we be taking this on? If we do take on a case surgically, we’ve learned a lot from our Mohs surgeons. And for those of us who are surgical oncologists, we should be thinking about CCPDMA [complete circumferential peripheral and deep margin assessment]. CCPDMA has a bunch of things under that umbrella; Mohs is one of them. But we can still do a comprehensive margin assessment, even if we’re not doing Mohs, and this is the kind of case that if we are going to resect it, we should reset it using CCPDMA. That permanent processing is going to give us our best chance at getting a reliable margin.

Glenn J. Hanna, MD: Great. And I would imagine that the location in the head and neck can be challenging because there are reconstructive implications and organ preservation concerns regarding things like the nose and function, the ear, the eye. Perhaps those are cases best invoking a head and neck surgical oncologist, as opposed to maybe just a dermatologist.

Kevin Emerick, MD: Getting beyond size, thinking about depth and invading into important muscles, important cranial nerves in the head and neck, and all the cosmetic part, it feels obvious, important functional aspects of our lips and how we eat and drink and talk, certainly our nose, in terms of how we breathe, our eye, the function of our ear—these are all important things that have a huge impact on a patient’s quality of life. The functional impact of these treatments is important for basal cell carcinoma.

This transcript has been edited for clarity.